Prosthesis for hernia repair

ABSTRACT

The present invention relates to a prosthesis (1) for hernia repair comprising a reinforcement layer (2), a first barrier layer (3) of anti-adhesion material covering at least a part of a surface of the reinforcement layer, and a second barrier layer of anti-adhesion material covering a remaining part of the surface of the reinforcement layer, the second barrier layer being formed of one or more flap member(s) (4).

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/384,435 filed Dec. 20, 2016, which claims benefit of and priority toEuropean Patent Application No. 16305063.6 filed Jan. 25, 2016, thedisclosures of each of the above-identified applications are herebyincorporated by reference in their entirety.

BACKGROUND OF THE INVENTION

The present invention relates to a prosthesis, for example a prosthesisfor treating hernias of the abdominal wall, comprising a reinforcementlayer capable of promoting tissue ingrowth, and two barrier layerscapable of preventing post-surgical adhesions on the prosthesis and onthe fixing means provided for fixing the prosthesis on the abdominalwall.

BRIEF SUMMARY OF THE INVENTION

The abdominal wall in humans is composed of fat and musclesinterconnected by fascias. The abdominal wall forms the anteriorenclosure of the abdominal cavity in which are lodged the viscera organssuch as the intestines, the stomach, etc. . . . said viscera organsbeing enclosed in the peritoneum. It sometimes happens that a break incontinuity occurs in the fascias, allowing part of the peritoneum toslip through and form a sac, or a hernia, containing either fat or partof the intestines, said sac protruding into the abdominal wall, therebycreating a defect in said wall and weakening it. Hernias or incisionalhernias (a hernia occurring through a parietal surgical scar) showthemselves in the form of a bulge at the surface of the skin and areclassed, for example, as umbilical or ventral hernias or incisionalhernias, depending on where they are located.

In order to repair a hernia defect, surgeons usually use a prosthesiscomprising a reinforcement layer of tissue ingrowth material, saidreinforcement layer replacing and/or strengthening the weakenedanatomical tissues. The efficiency of the prosthesis, hence the abilityto minimize the risks of recurrence, depends to a large extent on howwell the prosthesis is fixed to the surrounding biological tissues.

The prosthesis may be fixated over, under or within the defect. When theprosthesis is fixed under the defect, it must be introduced in theabdominal cavity in the first place and then anchored to the abdominalwall.

One method of hernia repair involves open surgery, with incision of theskin and then of the abdominal wall. In such a surgery, the prosthesisis introduced in the implantation site via the incision made in theskin. However, in this type of surgery, the surgeon has little space towork in and poor visibility.

Document U.S. Pat. No. 7,824,420 describes prosthesis intended to beused for hernia repair in an open surgery procedure. The prosthesisdescribed in this document comprises two layers of tissue ingrowthmaterial, namely material permitting tissue adhesion, joined together attheir periphery, one of the two layers being provided with a centralopening. The prosthesis therefore forms a sort of pocket accessible viasaid central opening. The prosthesis is introduced in the implantationsite via the incision of the skin and the hernia defect. The recessedlayer is positioned facing the abdominal wall with its central openingfacing the hernia defect, while the other layer is positioned facing theabdominal cavity. The fixing means and fixing tools are introduced intothe pocket formed by the prosthesis via the incision of the skin, thehernia defect and the central opening of the prosthesis. The surgeonthen fixes the prosthesis to the abdominal wall by attaching the tissueingrowth material of the recessed layer to the abdominal wall. To dothis, the surgeon fires fixing means through the tissue ingrowthmaterial of the recessed layer and into the abdominal wall from thepocket formed by the prosthesis.

Another method of hernia repair involves laparoscopic surgery, whereinthe prosthesis is conveyed in the abdominal cavity thanks to a trocarinto which it is placed. The advantages of laparoscopic hernia repairinclude reduced pain and hospital stay, rapid convalescence, quickerreturn to work, better functional and cosmetic results. In laparoscopicsurgery, the abdominal cavity is insufflated in order to create adequatespace therein for the surgeon to handle, position and anchor theprosthesis to the abdominal wall with the help of tools introduced inthe abdominal cavity via additional trocars. Such a surgery is known asthe intraperitoneal route as the prosthesis is positioned on theabdominal wall from the “inside” of the peritoneum, namely from theinside of the abdominal cavity.

In such procedures, one face of the prosthesis bears on the abdominalwall while the opposite face of the prosthesis faces the viscera organswhich are present in the abdominal cavity. It may then happen thatfollowing the surgical operation, some of the viscera organs adhere viaa fibrin bridging mechanism to some parts of the prosthesis that facethe abdominal cavity, such as for example the tissue ingrowth materialforming the prosthesis and/or some of the fixing means used for fixingthe prosthesis to the abdominal wall. Such a phenomenon may lead torisks for the patient such as transit dysfunction, occlusion ornecrosis. In order to avoid these potential post-operative adhesions, abarrier layer is usually provided on the face of the prosthesis that isintended to face the abdominal cavity.

Anyway, it has been observed that the intraperitoneal repair of herniadefect could still lead to postoperative complications and earlyrecurrences, in particular because of the exposure of the viscera organsto the parts of the prosthesis that face the abdominal cavity.

There is therefore the need for a prosthesis for the treatment ofhernia, that would limit the potential postoperative complications dueto the proximity between the prosthesis fixed to the abdominal wall andthe viscera organs present in the abdominal cavity.

The present invention aims at providing a prosthesis for the treatmentof hernia, in particular via the laparoscopic route, said prosthesishaving a specific structure allowing it to minimize the risks ofattachment of the viscera organs to the prosthesis posterior to theimplantation of the prosthesis and to its fixation to the abdominalwall.

A first aspect of the invention is a prosthesis for treating a herniadefect in the abdominal wall comprising:

At least one reinforcement layer, comprising a biocompatible porousmaterial, said reinforcement layer including a first surface intended toface the abdominal wall and a second surface opposite said firstsurface, said reinforcement layer being delimited by an outer edge,

At least one first barrier layer, comprising a biocompatibleanti-adhesion material, said first barrier layer including a firstsurface and a second surface opposite said first surface of the firstbarrier layer, the first surface of the first barrier layer coveringsubstantially at least a central part of the area of the second surfaceof said reinforcement layer, the second surface of said first barrierlayer being intended to face the abdominal cavity, said first barrierlayer being delimited by a peripheral outer edge,

At least one second barrier layer, said second barrier layer beingshaped and dimensioned so as to cover at least the part of the area ofthe second surface of said reinforcement layer that is not covered bythe first barrier layer, said second barrier layer being formed of oneor more flap members, each flap member being formed of a piece of sheetof biocompatible anti-adhesion material and having at least an outeredge attached to the second surface of the reinforcement layer, and afree inner edge.

Within the meaning of the present application, “porous material” isunderstood as a material having pores, voids or holes, that are open andare distributed uniformly or irregularly and promote cell colonizationand tissue ingrowth. The pores can be present in all types ofconfigurations, for example as spheres, channels, hexagonal forms.

Within the meaning of the present application, “anti-adhesion material”is to be understood as meaning a biocompatible material that exhibits acontinuous and smooth surface, for example non-porous, that minimizestissue attachment by preventing providing space for cell recolonization,at least for the time period corresponding to the time during whichpost-surgical adhesions are likely to occur.

In the present application, the terms “outer” and “inner” are to beunderstood with respect to the prosthesis itself. For example, whateverthe shape of the prosthesis, “inner” means in the direction of thecentre of the prosthesis while “outer” refers to the direction towardsthe periphery and exterior of the prosthesis.

The prosthesis of the invention allows forming one or more protectedspaces for positioning the fixing means intended to attach theprosthesis to the abdominal wall in a way allowing that said fixingmeans are prevented from entering in contact with the viscera organspresent in the abdominal cavity at least for the time periodcorresponding to the time during which post-surgical adhesions arelikely to occur. In particular, the structure of the second barrierlayer of the prosthesis of the invention, which is formed of one or moreflap members, allows creating protected spaces, adequate for positioningfixing means, such as clips, tacks, screws, spirals, straps, staples,suture or transfacial sutures, in a way that said fixing means areseparate from the abdominal cavity, and in particular from the visceraorgans present in said abdominal cavity, by a protective layerpreventing adhesions at least for the time period corresponding to thetime during which post-surgical adhesions are likely to occur after theimplantation of the prosthesis, said protective layer being formed ofthe one or more flap members. Moreover, the fact that the second barrierlayer is formed of one or more flap members provides for an easy accessto said protected spaces for the surgeon. Thanks to the shape and natureof the second barrier layer of the prosthesis of the invention, thesurgeon may easily fire fixing means, such as tacks, underneath the flapmember(s), at the right position for fixing safely the prosthesis to theabdominal wall, and with limited risks that said fixing means furthergenerate post-surgical adhesions with the organs of the abdominalcavity.

The prosthesis of the invention therefore allows completingintraperitoneal hernia repair with fewer risks of recurrence or ofpostoperative complications.

The prosthesis of the invention allows protecting the intestine andhollow organs of the abdominal cavity while efficiently strengtheningthe abdominal wall.

The prosthesis of the invention comprises at least one reinforcementlayer, comprising a biocompatible porous material, said reinforcementlayer including a first surface intended to face the abdominal wall anda second surface opposite said first surface. In embodiments, thereinforcement layer may consist in said biocompatible porous material.

The porous material suitable for the reinforcement layer of theprosthesis of the invention may comprise a sponge, a fibrous matrix or acombination of a sponge and of a fibrous matrix. For example, the spongecan be obtained by lyophilization of a gel, with pores being createdduring the lyophilization. The fibrous matrix can be any arrangement ofyarns or yarn portions creating pores between the yarns and/or yarnportions. For example, the fibrous matrix can be a textile, for exampleobtained by knitting or weaving or according to a technique forproducing a nonwoven.

In embodiments, the porous material, for example the sponge and/or thefibrous matrix, has pores with dimensions ranging from approximately 0.1to approximately 3 mm.

In embodiment, the porous material comprises, preferably consists in, amesh.

Within the meaning of the present application, a “mesh” is understood asan arrangement of biocompatible yarns, such as a knit, a woven fabric, anon-woven fabric, open-worked, that is to say provided with pores thatfavour recolonization of tissue. Such a mesh can be bioresorbable,permanent or partially bioresorbable. It is sufficiently flexible to befolded up and inserted into a trocar at the time of introduction intothe abdominal cavity. The mesh can be made from one layer of textile orseveral layers of textiles. Such meshes are well known to a personskilled in the art. The mesh that can be used according to the inventioncan be supplied in any shape whatsoever, for example rectangular,square, circular, oval, etc., and can then be cut to suit the shape ofthe hernia defect. For example, the mesh can have a generally squareshape or a rectangular shape. Alternatively, the overall shape of themesh can be circular or oval.

In one embodiment of the invention, the mesh is a knit. By virtue of themeshwork of the knit, it is possible to obtain openworked faces thatpromote cell recolonization after implantation. The knit can betwo-dimensional or three-dimensional.

Within the meaning of the present application, a two-dimensional knit isunderstood as a knit having two opposite faces linked to each other bymeshes but devoid of a spacer giving it a certain thickness: such a knitcan be obtained, for example, by knitting yarns on a warp knittingmachine or raschel knitting machine using two guide bars. Examples ofknitting two-dimensional knits suitable for the present invention aregiven in the document WO2009/071998.

According to the present application, a three-dimensional knit isunderstood as a knit having two opposite faces linked to each other by aspacer that gives the knit a significant thickness, said spacer itselfbeing formed from additional linking yarns in addition to the yarnsforming the two faces of the knit. Such a knit can be obtained, forexample, on a double-bed warp knitting or raschel knitting machine usingseveral guide bars. Examples of knitting three-dimensional knitssuitable for the present invention are given in the documentsWO99/05990, WO2009/031035 and WO2009/071998.

The porous material may comprise a bioresorbable or non-bioresorbablematerial.

In the present application, “bioresorbable” or “biodegradable” isunderstood to mean that the materials having this property are absorbedand/or degraded by the tissues or washed from the implantation site anddisappear in vivo after a certain time, which may vary, for example,from a few hours to a few years, depending on the chemical nature of thematerials.

The bioresorbable material suitable for the porous material of thereinforcement layer can be chosen from among the following bioresorbablematerials: polylactic acid (PLA), polycaprolactones (PCL),polydioxanones (PDO), trimethylene carbonates (TMC), polyvinyl alcohol(PVA), polyhydroxyalkanoates (PHA), oxidized cellulose, polyglycolicacid (PGA), polyethylene glycol (PE), copolymers of these materials, andmixtures thereof.

The non-bioresorbable material suitable for the porous material of thereinforcement layer can be chosen from among the followingnon-bioresorbable materials: polypropylenes, polyesters such aspolyethylene terephthalates, polyamides, silicones, polyether etherketone (PEEK), polyarylether ether ketone (PAEK) and mixtures thereof.

In one embodiment of the invention, the reinforcement layer of porousmaterial can be made from a gripping textile. Examples of grippingtextile are described in the document WO/0181667. For example, with saidgripping textile having a face provided with barbs, said face providedwith barbs can be directed towards the biological tissues, for examplethe abdominal wall, for helping in the fixing of the prosthesis to theabdominal wall.

The reinforcement layer may exhibit any shape as long as said shape islarge enough so as to cover efficiently the hernia defect to be treated.

In embodiments, said reinforcement layer has the shape of a rectangle,with or without rounded corners. In other embodiments, the reinforcementlayer may have an oval shape. Such embodiments are suitable, forexample, for the treatment of a ventral hernia. In embodiments, thereinforcement layer has the shape of a disc. Such an embodiment issuitable, for example, for the treatment of an umbilical hernia.

By virtue of its porous character, the reinforcement layer of theprosthesis of the invention is especially adapted to promote tissueingrowth via its first surface after implantation. The cells of theabdominal wall deeply colonize the porous structure of the reinforcementlayer via the first surface of the prosthesis.

The prosthesis of the invention further comprises at least a firstbarrier layer comprising a biocompatible anti-adhesion material, thefirst barrier layer including a first surface and a second surfaceopposite said first surface of the first barrier layer, the firstsurface of the first barrier layer covering substantially at least acentral part of the area of the second surface of the reinforcementlayer, the second surface of said first barrier layer being intended toface the abdominal cavity, said first barrier layer being delimited by aperipheral outer edge. In embodiments, the first barrier layer consistsin said biocompatible anti-adhesion material.

The first barrier layer is positioned in the prosthesis of the inventionso as to face the abdominal cavity and prevent the organs and otherviscera of the abdominal cavity from attaching themselves at least to acentral part of the prosthesis. The first barrier layer may adopt anyshape, oval, circular, rectangular, etc. so as to substantially coverthe central region of the second surface of the reinforcement layer. Aswill appear from the description below, the second barrier layer willcover the remaining part of the area of the second surface of thereinforcement layer, in other words the part of the area of the secondsurface of the reinforcement layer that is not covered by the firstbarrier layer, so that the entire area of the second surface of thereinforcement layer of the prosthesis is in the end covered byanti-adhesion material, either from the first barrier layer or from thesecond barrier layer.

In embodiments, the first barrier layer may cover the entire area of thesecond surface of the reinforcement layer. In embodiments, the firstbarrier layer may extend beyond the outer edge of the reinforcementlayer, for example on a distance ranging from 3 mm to 7 mm. The visceraorgans present in the abdominal cavity are therefore well prevented fromcontacting any porous material forming the reinforcement layer.

As seen above, the anti-adhesion material suitable for the first barrierlayer is a biocompatible material that exhibits a continuous and smoothsurface, for example non-porous, that minimizes tissue attachment bypreventing providing space for cell recolonization, at least for thetime period corresponding to the time during which post-surgicaladhesions are likely to occur.

Such an anti-adhesion material makes it possible in particular to avoidthe formation of undesirable and serious post-surgical fibrousadhesions, for example when the prosthesis is implanted in anintraperitoneal location.

The anti-adhesion material may be chosen from among bioresorbablematerials, non-bioresorbable materials and mixtures thereof. Thenon-bioresorbable anti-adhesion materials can be selected from amongpolytetrafluoroethylene, polyethylene glycols, polysiloxanes,polyurethanes, and mixtures thereof.

Said anti-adhesion material is preferably bioresorbable: thebioresorbable materials suitable for said anti-adhesion material can beselected from among collagens, oxidized celluloses, polyethylene glycol,polyacrylates, trimethylene carbonates, caprolactones, dioxanones,butyric or glycolic acid, lactic acid, glycolides, lactides,polysaccharides, for example chitosans, polyglucuronic acids, hyaluronicacids, dextrans, polyvinyl alcohol, polypeptides, polymers, copolymersand mixtures thereof.

The anti-adhesion material suitable for the first barrier layer makes itpossible to protect at least the central part, in embodiments theentire, area of the reinforcement layer of the prosthesis, at leastduring the initial phase of healing, that is to say the reinforcementlayer is not exposed to inflammatory cells such as granulocytes,monocytes, macrophages or even the multi-nuclear giant cells that aregenerally activated by the surgery.

In the case where the anti-adhesion material is made ofnon-bioresorbable materials, it thus protects the reinforcement layerbefore and after implantation, throughout the period of implantation ofthe prosthesis.

Moreover, by virtue of the anti-adhesion material, the fragilesurrounding tissues such as the hollow viscera, for example, areprotected particularly from the formation of serious and undesirablepost-surgical fibrous adhesions.

In the case where the anti-adhesion material comprises a bioresorbablematerial, it is preferable to choose a bioresorbable material that isresorbed only after a period of time ranging from a few days to a fewweeks, so as to ensure that the anti-adhesion material can perform itsfunction of protecting the intestine and the hollow organs during thedays after the operation and until the cell recolonization of theprosthesis in turn protects the fragile organs.

The anti-adhesion material forming the first barrier layer may forexample be provided as a coating or a film.

In embodiments, the first barrier layer is a coating. For example, asolution or suspension of an anti-adhesion material, for examplepolycaproplactone, is prepared by solubilising said anti-adhesionmaterial in a solvent. The solution or suspension may then be applied onthe part of the area of the second surface of the reinforcement layerthat is intended to be covered by the first barrier layer, for exampleat least a central part of the area of said second surface oralternatively the entire area of said second surface. For example, thesolution or suspension may be sprayed over the area to be coated inorder to form a homogeneous coating. The spraying step may be repeateduntil the desired amount of material is deposed on the second surface ofthe reinforcement layer. The solvent may be evaporated during thecoating process.

In other embodiments, the first barrier layer may be under the form of afilm of anti-adhesion material that is further applied on the area ofthe second surface of the reinforcement layer to be covered.

For example, a film suitable for the first barrier layer of theprosthesis of the invention is described in U.S. Pat. No. 6,235,869 andmay be prepared as follows: a copolymer of glycolide, lactide,trimethylene carbonate and e-caprolactone is synthetized and providedunder the form of pellets. The pellets are melt and extruded as a filmwith a controlled thickness. For example, the film thickness is between0.5 to 1.2 mil.

The film may be applied on the second surface of the reinforcement layeras follows: the reinforcement layer is placed in a lamination equipmentwith its second surface at the top. The film prepared as above describedis positioned upon the second surface of the reinforcement layer on thepart of the area of the second surface of the reinforcement layer thatis intended to be covered by the first barrier layer, for example atleast a central part of the area of said second surface or alternativelythe entire area of said second surface. The assembly may then be pressedunder controlled conditions of temperature and pressure so as tolaminate the film on the second surface of the reinforcement layer.

The prosthesis of the invention further comprises at least a secondbarrier layer, said second barrier layer being shaped and dimensioned soas to cover at least the part of the area of the second surface of saidreinforcement layer that is not covered by the first barrier layer, saidsecond barrier layer comprising one or more flap members, each flapmember being formed of a piece of sheet of biocompatible anti-adhesionmaterial, and having at least an outer edge attached to the secondsurface of the reinforcement layer and a free inner edge.

In the present application, by “flap member” is meant a piece of sheetof biocompatible anti-adhesion material having any shape, such asrectangular, annular, triangular, square, said shape defining an outeredge and an inner edge of said flap member, said outer edge beingattached to the second surface of the reinforcement layer, said inneredge being left free, so that the flap member is able to adopt a restconfiguration, in which the piece of sheet is substantially parallel tothe reinforcement layer, with the inner edge of the flap member being inthe direction of the centre of the reinforcement layer, and a liftedconfiguration, in which the inner edge of the flap member is pulled awayfrom the reinforcement layer.

In embodiments, the second barrier layer consists in said one or moreflap members.

The areas of the pieces of sheet of biocompatible anti-adhesion materialof the flap member(s) forming the second barrier layer amountaltogether, in a rest configuration of the flap members, namely parallelto the reinforcement layer, to a total area corresponding to at leastthe area of the second surface of the reinforcement layer that is notcovered by the first barrier layer, also hereinafter referred to as the“remaining area”. Some of the flap members may overlap with others. Inany case, the second barrier layer being shaped and dimensioned so as tocover at least the part of the area of the second surface of thereinforcement layer that is not covered by the first barrier layer, inthe end, the whole surface of the “remaining area” is safely covered byanti-adhesion material. As a result, the entire area of the secondsurface of the reinforcement layer is covered by anti-adhesion material,coming either from the first barrier layer or from the second barrierlayer.

In embodiments, the area resulting from the addition of the areas of theone or more flap member(s) is less than 120% of the area of the secondsurface of said reinforcement layer that is not covered by the firstbarrier layer, namely the remaining area. Implantation of excess foreignmaterial within the body of the patient is therefore avoided, whileensuring that the entire area of the second surface of the reinforcementlayer is safely covered by anti-adhesion material.

The flap member(s) of the second barrier layer is/are further intendedto cover the proximal ends of the fixing means, for example the heads ofthe tacks, that will be fired through the reinforcement layer in a viewof fixating the prosthesis to the abdominal wall. The piece of sheet ofanti-adhesion material forming one flap member is therefore preferablyshaped and dimensioned so as to cover entirely at least the proximal endof one fixing means, for example the head of a tack, that will protrudefrom the prosthesis once the prosthesis is fixed to the abdominal wall.In embodiments, one flap member may be formed of a piece of sheet shapedand dimensioned so as to cover a plurality of fixing means, inparticular the proximal ends of said fixing means, such as tacks' heads,protruding out of the second surface of the reinforcement layer once theprosthesis is fixed to the abdominal wall.

In this application, the distal end of a device must be understood asmeaning the end furthest from the hand of the user and the proximal endmust be understood as meaning the end closest to the hand of the user.

For example, whatever the shape of the piece of sheet forming a flapmember, it is recommended that the smallest dimension of said shapecorrespond at least to twice the length of the fixing means used tofixate the prosthesis to the abdominal wall, for example twice thelength of the tack used.

In embodiments, the smallest dimension of the shape of the piece ofsheet of anti-adhesion material forming a flap member ranges from about1 cm to 4 cm, preferably from 2 cm to 3 cm.

In embodiments, the second barrier layer comprises at least a first flapmember having the form of an annular band, the outer edge of said firstflap member being substantially attached to the second surface of thereinforcement layer along the outer edge of said reinforcement layer.

The position of the attaching line of the outer edge of the first flapmember may vary between the outer edge of the reinforcement barrierlayer and a line offset slightly from said outer edge, towards thecenter of the prosthesis, this attaching line being substantiallyparallel to the outer edge of the reinforcement layer.

The inner edge of the first flap member being free, the first flapmember forms a sort of skirt attached along the outer edge of thereinforcement layer, said skirt allowing access to an annular protectedspace defined between the skirt and the reinforcement layer. At the timeof fixating the prosthesis to the abdominal wall, the surgeon will beable to gain access easily to the protected space by lifting the freeinner edge of the skirt shaped flap member, to introduce the fixatingtool therein and fire therein the tacks. As a result, the heads of thetacks will be covered by the skirt formed by the first flap member,namely by the anti-adhesion material piece of sheet forming the firstflap member, so that the heads of the implanted tacks will not be incontact with the surrounding biological organs, at least during the timeperiod corresponding to the time during which post-surgical adhesionsare likely to occur. Because of the annular band shape of the skirtshaped flap member, the surgeon will be able to fire tacks all along theperimeter of the reinforcement layer and will be able to distribute thetacks as desired along this perimeter for an optimal fixation.

Because of the fact that the first flap member forming the secondbarrier layer is attached to the reinforcement layer along the outeredge of the reinforcement layer, for example at a distance of about 1 cmfrom the outer edge of the reinforcement layer, the surgeon can safelypush the fixating tool to the very end of the protected space, at thelocation where the second barrier layer and the reinforcement layer areattached together, and fire the tack so as to fix the reinforcementlayer to the abdominal wall. The surgeon may repeat this step as manytimes as needed all along the periphery of the line attaching the secondbarrier layer to the reinforcement layer. Suitable fixing means includeresorbable or non-resorbable clips, tacks, screws, spirals, straps,staples, suture or transfacial sutures. Thus, the surgeon is assured offixing the prosthesis to the biological tissues, for example theabdominal wall or peritoneum, without any risk of touching and/orstapling the surrounding organs, for example the intestines.

Moreover, once the surgeon has fixed the reinforcement layer of theprosthesis to the abdominal wall and the fixing tool has been removedfrom the implantation site, the heads of the tacks which have beenpositioned for fixing the prosthesis to the abdominal wall are locatedin the protected space delimited inbetween the second barrier layer andthe reinforcement layer. As a consequence, the heads of the tacks arecovered by the second barrier layer, in particular by the flap member(s)forming the second barrier layer, and are not in contact with theviscera organs present in the abdominal cavity.

In embodiments, said second barrier layer consists in said first flapmember having the form of an annular band, the outer edge of said firstflap member being substantially attached to the second surface of thereinforcement layer along the outer edge of said reinforcement layer. Asdescribed above, in such a case, the first flap member covers at leastthe part of the area of the second surface of said reinforcement layerthat is not covered by the first barrier layer, namely the remainingarea. In embodiments, the first flap member may have an area greaterthan the remaining area and it may therefore overlap a part of the firstbarrier layer. In any case, the entire area of the second surface of thereinforcement layer is covered by anti-adhesion material.

In other embodiments, the second barrier layer further comprises atleast a second flap member in addition to said first flap member, theouter edge of said second flap member being substantially attached tothe second surface of the reinforcement layer along a line locatedbetween the outer edge of the reinforcement layer and the outer edge ofthe first barrier layer. The presence of additional flap members allowscreating additional protected spaces for firing fixing means, for areinforced fixation. The additional flap members may be positioned infunction of the location of the reinforcement layer where a reinforcedfixation may be needed. Reinforced fixations may be needed for examplein case of large prosthesis intended to be implanted in obese patients.

For example, the second barrier layer may consist in a first flap memberhaving the form of a first annular band, the outer edge of said firstflap member being substantially attached to the second surface of thereinforcement layer along the outer edge of said reinforcement layer,and in a second flap member, said second flap member having the form ofa second annular band, said first and second flap members beingconcentrically positioned one with respect to the other, so that theouter edge of said second flap member is substantially attached to thesecond surface of the reinforcement layer along a line substantiallyparallel to the outer edge of the reinforcement layer, said line beinglocated between the outer edge of the reinforcement layer and the outeredge of the first barrier layer.

As described above, in such a case, the first flap member and the secondflap member cover at least the part of the area of the second surface ofsaid reinforcement layer that is not covered by the first barrier layer,namely the remaining area. In embodiments, the first flap member and thesecond flap member may together totalize an area greater than theremaining area. For example, the free inner edge of the first flapmember may overlap the attached outer edge of the second flap member,and the free inner edge of the second flap member may overlap the outeredge of the first barrier layer. In any case, the entire area of thesecond surface of the reinforcement layer is covered by anti-adhesionmaterial.

In such embodiments, the second flap member defines a second skirt, inaddition to the first skirt defined by the first flap member, allowingaccess to a second annular protected space defined between the secondskirt and the reinforcement layer, concentrically located with the firstannular protected space created by the first flap member in thedirection of the center of the reinforcement layer.

Such embodiments allow the surgeon to position a first line of tacks atthe location of the first protected space and a second line of tacks atthe location of the second protected space, for example for a reinforcedfixation of the prosthesis.

Alternatively, for example, the second barrier layer may consist in afirst flap member having the form of an annular band, the outer edge ofsaid first flap member being substantially attached to the secondsurface of the reinforcement layer along the outer edge of saidreinforcement layer, and in a second and a third flap members, each ofsaid second and third flap members having the form of a tape portion,the respective outer edges of said second and third flap members beingsubstantially attached to the second surface of the reinforcement layeralong line(s) located between the outer edge of the reinforcement layerand the outer edge of the first barrier layer, said line(s) beingintended to be positioned in regards of the vicinity of the edges of thehernia defect.

Such embodiments allow proceeding to a fixation technique whereadditional tacks may be positioned at the vicinity of the edges of thedefect to be treated.

In embodiments, the outer edge of said first flap member is attachedalong the outer edge of said reinforcement layer in a continuous way.The surgeon therefore knows that he can apply the tacks or the staplesat any point in the space created inbetween the first flap member andthe reinforcement layer, without having to look for a precise location.

In embodiments, the outer edge of said first flap member is attached tothe second surface of the reinforcement layer so as to define anattaching line which is offset towards a center of the prosthesis fromabout 0.5 to about 2 cm, preferably about 1 cm, from the outer edge ofsaid reinforcement layer. Such embodiments allow ensuring that thefixing means, such as the clips, tacks, screws, spirals, straps,staples, suture or transfacial sutures, will not move closer to theouter edge of the prosthesis and in particular of the reinforcementlayer, than 1 cm. The surgeon is therefore ensured that the fixing meanswill be positioned so as to guaranty an efficient fixing. It may then beuseful that the first barrier layer covers the entire area of the secondsurface of the reinforcement layer, and optionally goes beyond the outeredge of the reinforcement layer, to ensure that the entire area of thesecond surface of the reinforcement layer is covered by anti-adhesionmaterial.

In embodiments, said first barrier layer covering the entire area of thesecond surface of the reinforcement layer, the outer edge(s) of the flapmember(s) forming the second barrier layer is/are attached to the secondsurface of the reinforcement layer via the intermediate of the firstbarrier layer.

In embodiments, the outer edge(s) of the flap member(s) forming thesecond barrier layer is/are attached to the second surface of thereinforcement layer by attaching means selected from the groupcomprising ultrasonic welding, hot compression welding, gluing andcombinations thereof.

For example, when the first barrier layer is intended to cover theentire area of the second surface of the reinforcement layer and whenthe second barrier layer is intended to consist in one flap memberhaving the form of an annular band, the first and second barrier layersmay be attached one to the other in a separate step, the assembly of thetwo attached layers being thereafter attached to the reinforcementlayer.

The step of attaching the first barrier layer to the second barrierlayer may be performed by ultrasonic welding as follows: a layer of thefirst barrier layer is placed on an ultrasonic press anvil, the anvilbeing protected by a peelable film of a polymer having a melting pointhigher than the temperature intented to be set for the lamination step,said peelable film being intended to prevent the welding of the firstbarrier layer on the ultrasonic press anvil. A second peelable film ofthe same polymer, shaped into a similar but smaller shape than thefuture first barrier layer, is laid on the first barrier layer so as tolet non protected only a peripheral region of the first barrier layer.

The annular band shaped second barrier layer is placed onto the secondpeelable film, so as to overlap both the unprotected peripheral regionof the first barrier layer and a peripheral region of the secondpeelable film. A third peelable film of the same polymer as above,having the same shape of the second barrier layer is laid on the top ofthe second barrier layer to prevent the welding of the second barrierlayer on the ultrasonic press sonotrod.

The sonotrod of the ultrasonic welding press is lowered to press thesecond barrier layer onto the first barrier layer. Ultrasonic vibrationis applied, and the second barrier layer is welded to the future firstbarrier layer in the peripheral region of the first barrier layer.

The first peelable film is removed, and the assembly of the first andsecond barrier layers is afterward placed on the second surface of thereinforcement layer coated with a polymer glue.

A hot press is then used to apply a pressure onto the three layers so asto hotmelt the gluing polymer coating and glue the first barrier layeronto the reinforcement layer. Because of the presence of the second andthird peelable antiadhesion films, the second barrier layer is preventedto adhere onto the first barrier layer and onto the hot press.

By removing the second and third peelable films, a prosthesis of theinvention is obtained, in which the first barrier layer covers theentire area of the second surface of the reinforcement layer and thesecond barrier is an annular band shaped flap member, the outer edge ofwhich is attached to the first barrier layer and therefore to thereinforcement layer. In other words, the outer edge of the secondbarrier layer is attached to the reinforcement layer via theintermediate of the first barrier layer.

In the prosthesis of the invention, the second barrier layer is stronglyassembled with the first barrier layer and/or the reinforcement layerand the integrity of the assembly is not compromised by the movement ofthe tacker shaft in the protected space created by the second barrierlayer at the moment the surgeon proceeds to the fixing of the prosthesisto the abdominal wall.

The anti-adhesion material suitable for forming the second barrier layermay be defined in the same way as the anti-adhesion material definedabove for the first barrier layer. The anti-adhesion material used forforming the second barrier layer may be identical or different from thatused for forming the first barrier layer. Moreover, the anti-adhesionmaterial used for forming the flap member(s) of the second barrier layermay be identical or different from one flap member to the other.

The anti-adhesion material forming the flap members(s) of the secondbarrier layer makes it possible to protect at least the remaining area,in other words, the part of the area of the second surface of saidreinforcement layer that is not covered by the first barrier layer, atleast during the initial phase of healing, that is to say thereinforcement layer is not exposed to inflammatory cells such asgranulocytes, monocytes, macrophages or even the multi-nuclear giantcells that are generally activated by the surgery.

Indeed, at least during the initial phase of healing, the duration ofwhich can vary between 5 and 10 days approximately, only theanti-adhesion material of the first barrier layer and of the secondbarrier layer can be accessed by the various factors such as proteins,enzymes, cytokines or cells of the inflammatory line.

For example, the flap member(s) forming the second barrier layers may bepieces of films of anti-adhesion material as described above for thefirst barrier layer.

In embodiments, said second barrier layer is provided with markingsintended to indicate to the surgeon where to locate one or more fixingmeans for fixing the prosthesis to the abdominal wall. For example, saidmarkings may be under the form of colored spots located on the surfaceof said second barrier layer intended to face the abdominal cavity. Inembodiments, the markings, such as colored spots, are regularly spacedfrom one another along a perimeter of said second barrier layer. Forexample, the markings are distant 1.5 cm from one another. Suchembodiments allow the surgeon to easily position the fixing means, suchas tacks, at intervals of 1.5 cm. Such a fixation technique is usuallyassociated with a low recurrence rate of the hernia (see Bittner, R., etal., Guidelines for laparoscopic treatment of ventral and incisionalabdominal wall hernias (International Endohernia Society (IEHS)—Part 1.Surgical Endoscopy, 2014. 28(1): p. 2-29)

In embodiments, the second barrier layer may be provided withidentification means for distinguishing said second barrier layer fromsaid first barrier layer. For example, the second barrier layer may showa color different than that of the first barrier layer. In otherexamples, the second barrier layer may be provided with specific designsdrawn on flap member(s), such as geometric figures, etc.

In embodiments, the free inner edge(s) of said flap member(s) formingthe second barrier layer is/are provided with one or more projectingtab(s) intended to help the surgeon lift said flap member(s) from saidreinforcement layer. Such embodiments allow the surgeon lift easily theflap member in order to introduce the fixing means within the protectedspace formed between the flap member and the reinforcement layer. Thegesture of the surgeon is therefore facilitated.

In embodiments, the flap member(s) forming the second barrier layeris/are provided on their surface regarding the reinforcement layer orthe first barrier layer with a tacky layer of biocompatible materialscapable of sticking to said reinforcement layer or first barrier layer.It is therefore possible to stick the flap member(s) to thereinforcement layer or first barrier layer once the fixing means hasbeen positioned, the flap member(s) thereby covering the proximal endsof the fixing means with reinforced safety. The biocompatible materialssuitable for forming the tacky layer may be selected fromcollagen-based, polylactone-based, polylactic, polyethylene glycol,polysaccharides and/or polyvinyl alcohol based surgical adhesives,fibrin glues, and combinations thereof.

Another aspect of the invention is a method for treating a herniadefect, in particular a ventral hernia defect, comprising the followingsteps:

-   -   a prosthesis as disclosed herein is provided,    -   the prosthesis is conveyed into the abdominal cavity after the        hernia sac has been reduced, for example by means of a trocar,    -   the prosthesis is fixed to the abdominal wall with the first        surface of the reinforcement layer facing the abdominal wall, by        means of tacks fired in the protected space created between the        first barrier layer and the second barrier layer, so that, once        the prosthesis is fixed, the second barrier layer covers the        heads of the tacks, thereby preventing the viscera organs from        entering in contact with the tacks.

BRIEF DESCRIPTION OF THE DRAWING

The present invention will become clearer from the following descriptionand from the attached drawings, in which:

FIG. 1 is an exploded view of a first embodiment of the prosthesis ofthe invention,

FIG. 2 is a bottom perspective view of the prosthesis of FIG. 1,

FIG. 3 is a cross sectional view of the prosthesis of FIG. 2 taken alongplane I-I′,

FIG. 4 is a bottom view of another embodiment of the prosthesis of theinvention,

FIG. 5 is a bottom view of another embodiment of the prosthesis of theinvention,

FIG. 6 is a bottom view of another embodiment of the prosthesis of theinvention,

FIG. 7A is a cross section view of the prosthesis of FIG. 6 taken alongplane II-II′,

FIG. 7B is a cross section view of an alternative embodiment of theprosthesis of FIG. 6,

FIG. 8 is a bottom view of another embodiment of the prosthesis of theinvention,

FIG. 9 is a sectional view of a median abdominal hernia,

FIG. 10 is a sectional view of the hernia of FIG. 9 once the hernia sac(not shown) has been reduced and the prosthesis of FIG. 1 has beenintroduced in the abdominal cavity,

FIG. 11 is a cross sectional view showing the tacking of the prosthesisof FIG. 1 to the abdominal wall,

FIG. 12 is a cross sectional view showing the prosthesis of FIG. 1 fixedto the abdominal wall, with the first barrier layer of the prosthesiscovering the heads of the tacks.

DETAILED DESCRIPTION OF THE INVENTION

With reference to FIGS. 1-3 is shown a prosthesis 1 in accordance withthe present invention intended to be used in the treatment of hernia, inparticular ventral hernia, via the laparoscopic route. The prosthesis 1comprises a reinforcement layer 2, intended to provide strength andmechanical properties to the prosthesis 1, a first barrier layer 3intended to limit and prevent the formation of adhesions between thereinforcement layer 2 and the organs of the abdominal cavity (see FIGS.10-12), and a second barrier layer 4 intended to prevent the formationof adhesions between the organs of the abdominal cavity 109 and thefixing means for fixing the prosthesis 1 to the abdominal wall 104.

The reinforcement layer 2 is made of a biocompatible porous material, inparticular capable of promoting tissue ingrowth. The reinforcement layermay be under the form of a sponge, for example obtained bylyophilisation of a polymeric composition, a fibrous matrix such as atextile or combinations thereof. The reinforcement layer preferablyshows mechanical properties allowing it to perform its function ofstrengthening and repairing the abdominal wall.

Reinforcement layers are well known in the art. In embodiments, thereinforcement layer may be a textile, such as a bidimensional porousknit or a three-dimensional porous knit.

With reference to FIGS. 1-3, the reinforcement layer 2 has the shape ofa rectangle, with rounded corners. In other embodiments, thereinforcement layer may have an oval shape. Such embodiments aresuitable, for example, for the treatment of a ventral hernia. Inembodiments, the reinforcement layer has the shape of a disc. Such anembodiment is suitable, for example, for the treatment of an umbilicalhernia. The reinforcement layer may exhibit any shape as long as saidshape is large enough so as to cover efficiently the hernia defect to betreated.

The reinforcement layer 2 has a first surface 2 a and a second surface 2b, opposite the first surface. On the example shown, the first surface 2a is intended to face the abdominal wall (see FIGS. 10-12). Thereinforcement layer 2 is delimited by an outer edge 2 c and has a centerC.

The prosthesis 1 further comprises a first barrier layer, under the formof a film 3 on the example shown. The first barrier layer or film 3 ismade of a biocompatible anti-adhesion material. The film 3 shows a firstsurface 3 a and a second surface 3 b, opposite the first surface 3 a.The first barrier layer or film 3 is delimited by an outer edge 3 c.

The anti-adhesion material forming the first barrier layer or film 3allows preventing post surgical adhesions between the viscera organs ofthe abdominal cavity and the porous material forming the reinforcementlayer 2. The first surface of the first barrier layer, such as the film3, covers at least a central part of the area of the second surface 2 bof the reinforcement layer 2. In the example shown on FIGS. 1-3, thefirst surface of the first barrier layer, such as the film 3, covers theentire area of the second surface 2 b of the reinforcement layer 2. Assuch, the second surface of the first barrier layer, such as the film 3,is intended to face the abdominal cavity and therefore protects theviscera organs of the abdominal cavity from the reinforcement layer 2.

In other embodiments (see FIG. 7B), the first surface of the firstbarrier layer, such as the film 3, covers only a central part of thearea of the second surface 2 b of the reinforcement layer 2.

The anti-adhesion material may be chosen from among bioresorbablematerials, non-bioresorbable materials and mixtures thereof. Thenon-bioresorbable anti-adhesion materials can be selected from amongpolytetrafluoroethylene, polyethylene glycols, polysiloxanes,polyurethanes, and mixtures thereof.

The anti-adhesion material is preferably bioresorbable: thebioresorbable materials suitable for said anti-adhesion material can beselected from among collagens, oxidized celluloses, polyethylene glycol,polyacrylates, trimethylene carbonates, caprolactones, dioxanones,butyric or glycolic acid, lactic acid, glycolides, lactides,polysaccharides, for example chitosans, polyglucuronic acids, hyaluronicacids, dextrans, and mixtures thereof.

For example, the film 3 of FIGS. 1-3 is a film of a copolymer ofglycolide, lactide, trimethylene carbonate and e-caprolactone, thepreparation of which is described in U.S. Pat. No. 6,235,869. The filmmay be applied on the reinforcement layer 2 by a lamination process.

In other embodiments, the film 3 may be a non porous collagen film or abioabsorbable collagen film based on oxidized collagen with polyethyleneglycol. Such films based on collagen may be obtained by application onthe second surface of the reinforcement layer of a solution based oncollagen and by gelification of the solution thereon.

In other embodiments, the first barrier layer is a coating obtained byspraying a solution or a suspension of an anti-adhesion material on thesecond surface of the reinforcement layer 2.

The prosthesis 1 further comprises a second barrier layer, consisting ina flap member under the form of a first skirt 4 on FIGS. 1-3, made of abiocompatible anti-adhesion material. The first skirt 4 is a piece ofsheet of biocompatible anti-adhesion material under the form of anannular band shaped film. The anti-adhesion material forming the secondbarrier layer or first skirt 4 allows preventing post surgical adhesionsbetween the viscera organs of the abdominal cavity and the fixing meansused to fix the prosthesis to the abdominal wall, as will appear fromthe description below.

The anti-adhesion material forming the second barrier layer, namely thefirst skirt 4, may be chosen among the same materials as described abovefor the anti-adhesion material forming the first barrier layer. Theanti-adhesion material forming the first skirt 4 may be identical ordifferent than the anti-adhesion material forming the film 3.

For example, the first skirt 4 is made of a film of a copolymer ofglycolide, lactide, trimethylene carbonate and e-caprolactone, thepreparation of which is described in U.S. Pat. No. 6,235,869.

The first skirt 4 has an outer edge 5 a and an inner edge 5 b. Theannular band forming the first skirt 4 has preferably a width,corresponding to the length measured along a direction aligned on aradius of the reinforcement layer extending from the center C of thereinforcement layer to a point of the outer edge of the reinforcementlayer, ranging from about 1 cm to 4 cm, preferably from 2 cm to 3 cm.The first skirt 4 is therefore particularly adapted for covering theproximal ends of the fixing means used for fixing the prosthesis 1 tothe abdominal wall.

The first skirt 4 further shows a first surface 4 a, intended to facethe first barrier layer or film 3, and a second surface 4 b intended toface the abdominal cavity (see FIGS. 10-12). In embodiments (not shown),the first skirt 4 is provided on its surface regarding the film 3 with atacky layer of biocompatible materials capable of sticking to film 3.The biocompatible materials suitable for forming the tacky layer may beselected from collagen-based, polylactone-based, polylactic,polyethylene glycol, polysaccharides and/or polyvinyl alcohol basedsurgical adhesives, fibrin glues, and combinations thereof.

In the example shown, with reference to FIG. 3, the outer edge 5 a ofthe first skirt 4 is attached to the second surface of the reinforcementlayer 2 along the outer edge 2 c of the reinforcement layer 2 by theintermediate of the film 3. In other words, the outer edge 5 a of thefirst skirt 4 is therefore attached along the outer edge 3 c of the film3. The inner edge 5 b of the first skirt 4 is left free.

Preferably, the outer edge 5 a of the first skirt 4 is attached alongthe outer edge 3 c of the film 3 in a continuous way. For example, theouter edge 5 a of the first skirt 4 is attached to the film 3 so as todefine an attaching line 6 which is offset towards a center of theprosthesis from about 0.5 to about 2 cm, preferably about 1 cm, fromsaid outer edge. As will appear from the description of FIGS. 10-12below, such embodiments guaranty that the fixing means, such as clips,tacks, screws, spirals, straps, staples, suture or transfacial sutures,will not move too close to the outer edge of the prosthesis 1.

The first barrier layer, such as the film 3, and the second barrierlayer, such as the first skirt 4, may be attached one to the other byattaching means selected from the group comprising ultrasonic welding,hot compression welding, gluing and combinations thereof.

For example, in case the anti-adhesion material forming the first andsecond barrier layers is selected from polylactic acid, polyglycolicacid, trimethylene carbonates, polyethylene glycol, polycaprolactone,and combinations thereof, the first barrier layer and the second barrierlayer may be attached one to the other via ultrasonic welding byapplying pressure and piezo energy to ensure local fusion of the twobarriers.

Alternatively, in case the anti-adhesion material forming the first andsecond barrier layers is a collagen or derivatives thereof, the firstbarrier layer and the second barrier layer may be attached one to theother via a gluing agent, for example a gluing agent capable of locallysolubilising both barriers in order to fusion them. The gluing agent maybe a collagen water solution, with or without a crosslinking agent. Forexample, in contact with such a collagen water solution, the first andsecond barriers' surfaces will tend to melt, and by a drying process thefirst and second barriers will be unified.

For example, in the present example, the film 3 and the first skirt 4being each made of a film of a copolymer of glycolide, lactide,trimethylene carbonate and e-caprolactone, the first skirt 4 is attachedto the film 3 by ultrasonic welding. The first skirt 4 is thereforesecurely attached to the film 3.

As shown on FIG. 3 and as will appear from the description below, theshape of the flap member forming the second barrier layer, namely thefirst skirt 4, and the way it is attached to the first barrier layer,e.g. the film 3, allow creating an adequate protected space 11 locatedbetween the film 3 and the first skirt 4 for lodging the fixing means,such as tacks, intended to fix the prosthesis to the abdominal wall (seeFIG. 12).

With reference to FIGS. 4-8 are shown other embodiments of theprosthesis 1 of the invention. In these Figures, references designatingthe same elements as in the prosthesis 1 of FIGS. 1-3 have beenmaintained.

With reference to FIG. 4 is shown an alternative embodiment of aprosthesis 1 of the invention, provided with markings 7 intended toindicate to the surgeon where to locate one or more fixing means forfixing the prosthesis 1 to the abdominal wall. On the example shown, themarkings 7 are regularly spaced from one another along a perimeter ofthe second barrier layer or first skirt 4. With reference to FIG. 4, themarkings 7 are under the form of colored spots located on the surface 4b of the first skirt 4 which is intended to face the abdominal cavity:the fixing means are optimally positioned underneath the first skirt 4,at points corresponding to the localization of the colored spots. Inother embodiments not shown, the markings may have the shape of crosses,triangles, etc.

In embodiments, the markings are distant 1.5 cm from one another. Suchembodiments allow the surgeon to easily position the fixing means, suchas tacks, at intervals of 1.5 cm. Such a fixation technique is usuallyassociated with a low recurrence rate of the hernia.

Alternatively, markings, such as a dotted line, may be provided on thereinforcement layer 2 itself.

In embodiments, the second barrier layer or first skirt 4 may beprovided with identification means for distinguishing said first skirt 4from said first barrier layer or film 3. For example, the first skirt 4may show a color different than that of the film 3. In otherembodiments, the first skirt 4 may be provided with specific designsdrawn on flap member(s), such as geometric figures, etc.

With reference to FIG. 5 is shown an alternative embodiment of aprosthesis 1 of the invention, wherein the inner edge 5 b of the secondbarrier layer or first skirt 4, is provided with a projecting tab 8. Theprojecting tab 8 is intended to help the surgeon lift the first skirt 4from the film 3. In particular, the surgeon may grasp the projecting tab8 with a grasper or other instrument so as to pull on it and lift theinner edge 5 b of the first skirt 4, thereby opening a larger access tothe protected space located between the first skirt 4 and the film 3.

In embodiments not shown, the first skirt 4 could be provided with oneor more tabs, positioned anywhere along the length of its inner edge,for example positioned along the mid-line of a side of the inner edgewhere a minimal amount of force will create a greater separation betweenthe first skirt 4 and the reinforcement layer 2 along that side of thefirst skirt 4.

With reference to FIGS. 6 and 7A, is shown an alternative embodiment ofa prosthesis 1 of the invention, wherein the second barrier layercomprises a first flap member, under the form of a first skirt 4 like inFIGS. 1-3, and a second flap member, under the form of a second skirt 9.In the example shown, the second barrier layer consists in said firstand second skirts (4, 9). The second skirt 9 is a piece of sheet ofbiocompatible anti-adhesion material under the form of an annular bandshaped film. The anti-adhesion material used for the second skirt 9 maybe the same or different than the anti-adhesion material used for thefirst skirt 4.

For example, the second skirt 9 is made of a film of a copolymer ofglycolide, lactide, trimethylene carbonate and e-caprolactone, thepreparation of which is described in U.S. Pat. No. 6,235,869.

In the Example shown on FIGS. 6 and 7A, the second skirt 9 is locatedbetween the first barrier layer or film 3 and the first flap member orfirst skirt 4. The second skirt 9 is delimited by an outer edge 10 a andan inner edge 10 b. The outer edge 10 a of the second skirt 9 issubstantially attached along the outer edge 2 c of the reinforcementlayer 2 by the intermediate of the outer edge 3 c of the film 3 formingthe first barrier layer.

Moreover, as shown on FIGS. 6 and 7A, the inner edge 10 b of the secondskirt 9 is free and extends beyond the inner edge 5 b of the annularband film 4 in the direction of the center C (see FIG. 1) of thereinforcement layer 2.

The second skirt 9 may be attached to the film 3 and to the first skirt4 by the same methods as described above for attaching the film 3 to thefirst skirt 4. For example, in the present example, the film 3, thesecond skirt 9 and the first skirt 4 being each made of a film of acopolymer of glycolide, lactide, trimethylene carbonate ande-caprolactone, the first skirt 4, second skirt 9 and film 3 may beattached altogether by ultrasonic welding. The first skirt 4, secondskirt and film 3 are therefore securely attached together.

As shown on FIG. 7A, the respective shapes and attachment structures ofthe first skirt 4 and of the second skirt 9 allow creating two differentprotected spaces (12, 13) for lodging fixing means, such as tacks,intended to fix the prosthesis to the abdominal wall. With reference toFIG. 7A, a first protected space 12 is created between the film 3 andthe second skirt 9, and a second protected space 13 is created betweenthe second skirt 9 and the first skirt 4.

With reference to FIG. 7B, is shown an alternative embodiment of aprosthesis 1 of FIG. 7A in which the first barrier layer under the formof the film 3 covers only a central part of the area of the secondsurface of the reinforcement layer 2 and the outer edge 10 a of thesecond skirt 9 is substantially attached to the second surface of thereinforcement layer 2 along a line located between the outer edge 2 c ofthe reinforcement layer 2 and the outer edge 3 c of the first barrierlayer or film 3. In particular, the first skirt 4 and the second skirt 9are concentrically positioned one with respect to the other, so that theouter edge 10 a of the second skirt 9 is substantially attached to thesecond surface of the reinforcement layer 2 along a line substantiallyparallel to the outer edge 2 c of the reinforcement layer 2, the linebeing located between the outer edge 2 c of the reinforcement layer 2and the outer edge 3 c of the first barrier layer formed by the film 3.

As appears from FIG. 7B, the second barrier layer, which consists in thefirst skirt 4 and the second skirt 9, is shaped and dimensioned so as tocover at least the part of the area of the second surface of thereinforcement layer 2 that is not covered by the first barrier layer orfilm 3. In particular, in the example shown, the inner edge 5 b of thefirst skirt 4 forming the first flap member overlaps the outer edge 10 aof the second skirt 9 forming the second flap member, and the inner edge10 b of the second skirt 9 overlaps the outer edge 3 c of the film 3forming the first barrier layer. As a result, the entire area of thesecond surface of the reinforcement layer 2 is safely covered byanti-adhesion material, said anti-adhesion material being providedeither by the film 3 forming the first barrier layer or by the firstskirt 4 or the second skirt 9 forming the first and second flap membersof the second barrier layer. Such an embodiment allows reducing theamount of anti-adhesion material implanted into the body of the patient,while ensuring a safe covering of the entire area of the second surfaceof the reinforcement layer 2 by an anti-adhesion material. Moreover,when the anti-adhesion materials forming the first barrier layer and thesecond barrier layer are biodegradable, such embodiments allow an evendegradation profile for the first and second barrier layers across theentire second surface of the reinforcement layer 2.

Such embodiments of the prosthesis 1 of the invention as shown on FIGS.7A and 7B are particularly useful for allowing the surgeon to complete areinforced fixation. Indeed, when the hernia defect to be repaired islarge, it may be useful to fix the prosthesis 1 to the abdominal wallusing two sets of fixing means. For example, a first set of tacks may bepositioned according to a circle configuration in the vicinity of theedges of the defect. In the present example, this first circle of tackscould be positioned in the first protected space 12 of prosthesis 1 ofFIGS. 6-7B, with for example a regular space between two adjacent tacks,such as 1 cm. Then, a second set of tacks may be positioned according toa second circle, of larger diameter, in the vicinity of the peripheralouter edge of the prosthesis, preferably at a distance of about 1 cm setback from this peripheral outer edge, as explained above. In the presentexample, this second circle of tacks could be positioned in the secondprotected space 13 of prosthesis 1 of FIGS. 6-7B, with for example aregular space between two adjacent tacks, such as 1 cm. Once theprosthesis 1 is fixed to the abdominal wall, the second skirt 9 coversthe heads of the tacks positioned on the first circle, and the firstskirt 4 covers the tacks of the second circle. The viscera organs of theabdominal cavity are therefore well protected from the fixing means,such as tacks, of the prosthesis, and potential surgical adhesionbetween the tacks and the viscera organs are avoided.

With reference to FIG. 8 is shown an alternative embodiment of aprosthesis 1 of the invention, in which the second barrier layercomprises a first flap member, under the form of a first skirt 4 like inFIGS. 1-3, and a second and third flap members, the second and thirdflap members each being under the form of a longitudinal tape portion 14intended to be positioned in regards of edges of the hernia defect oncethe prosthesis 1 is implanted. In the example shown, the second barrierlayer consists in the first skirt 4 and the two longitudinal tapeportions 14. The two longitudinal tape portions 14 extend from a smallside of the prosthesis 1 to the other. The outer edge (not visible) ofeach longitudinal tape portion 14 is attached to the reinforcement layerby the intermediate of the film 3, the inner edge 14 b of eachlongitudinal tape 14 being left free.

Such embodiment allows creating two longitudinal protected spaces 15,located between the film 3 and the tape portions 14, for lodging fixingmeans, such as tacks, in the vicinity of the defect edges.

The method of treating a hernia defect with the prosthesis 1 of FIGS.1-3 will now be described in reference to FIGS. 9-12. In FIGS. 11 and12, the prosthesis of FIGS. 1-3 is drawn in a simplified manner so as toclarify the Figures.

FIG. 9 shows a hernia defect 100 of the abdominal wall 101,characterized by a break in continuity of the fascia 102 surrounding therectus muscles 103 and by a passage through the peritoneum 104 forming asac, the hernial sac 105, which contains either fat (greater momentum)or part of the viscera 106, and which thus exerts pressure on the fattytissues 107 and lies flush with the skin 108. Treatment of a herniadefect 100 involves repositioning and maintaining the viscera 106 in theabdominal cavity 109.

FIG. 10 shows the hernia defect from FIG. 9 after insufflation of theabdominal cavity 109 and reduction of the hernial sac 105 by the surgeonby laparoscopic surgery. The viscera organs are not shown in FIG. 10:they have been pushed back towards the abdominal cavity 109. Once thehernial sac 105 is reduced, the prosthesis 1 of FIGS. 1-3 is introducedin the abdominal cavity 109 by means of a trocar (not shown) andpositioned with the first surface 2 a of the reinforcement layer 2facing the abdominal wall 101 and peritoneum 104, as shown on FIG. 10.

The surgeon then moves the prosthesis 1 closer to the peritoneum104/abdominal wall 101 so that the first surface 2 a of the prosthesis 1bears on the peritoneum 104/abdominal wall 101; the surgeon grasps theinner perimeter 5 b of the first skirt 4 with a laparoscopic tool so asto lift the first skirt 4 and gain access to the protected space 11. Atacker 17 is then introduced in the abdominal cavity 109 by means of atrocar (not shown). The distal end of the tacker 17 is introduced in theprotected space 11 and a tack 16 is fired in the direction of theperitoneum 104/abdominal wall 101, as shown on FIG. 11.

In embodiments where the attaching line 6 of the prosthesis 1 iscontinuous and offset towards the center of the prosthesis 1 from theouter edge 3 c of the first barrier layer of film 3, as shown on FIGS.3, 11 and 12, the surgeon may feel particularly comfortable with thegesture of introducing the distal end of the tacker 17 into theprotected space 11 and of firing a tack 16, as he is ensured that thetacks 16 will not move too close to the outer edge of the prosthesis 1.In addition, because of the strong and efficient attaching between thesecond barrier layer or first skirt 4 and the reinforcement layer 2 orfirst barrier layer or film 3, the surgeon knows that he can firmly pushon the tacker 17 in the distal direction and therefore in the directionof the abdominal wall without fearing that the second barrier layerseparates from the first barrier layer and/or from the reinforcementlayer. The integrity of the assembly of the reinforcement layer/firstbarrier layer and second barrier layer is not compromised by themovement of the tacker 17 in the protected space 11.

The same operation is repeated for each tack 16, as many times as deemednecessary by the surgeon in order to obtain an efficient fixation of theprosthesis 1 to the peritoneum 104/abdominal wall 101.

With reference to FIG. 12, two tacks 16 are shown after they have beenfired in the protected space 11. As shown on this Figure, the tacks 16fix both the reinforcement layer 2 and the first barrier layer of film 3to the peritoneum 104/abdominal wall 101 with their proximal end, namelytheir head 16 a, protruding in the protected space 11. The first skirt 4covers the heads 16 a of the tacks 16 so that no part of the tacks 16 isin contact with the viscera organs (not shown) present in the abdominalcavity 109.

As a result, the risk of recurrence provoked by the formation ofpost-surgical adhesions between the fixing means, such as tacks 16, andthe viscera organs of the abdominal cavity 109 is dramatically decreasedwith the prosthesis 1 of the invention.

In embodiments, the first skirt 4 is provided on its surface regardingthe film 3 with a tacky layer of biocompatible materials, and thesurgeon may cover the head 16 a of each tack 16 and then stick the firstskirt 4 to the film 3 for a reinforced protection and reliableseparation of the tack's head from the surrounding biological issues ofthe abdominal cavity.

The prosthesis of the invention therefore allows completingintraperitoneal repair with fewer risks of recurrence or ofpostoperative complications.

1-17. (canceled)
 18. A method of treating a hernia defect in anabdominal wall including: introducing a prosthesis into an abdominalcavity, the prosthesis including, at least one reinforcement layer,including a biocompatible porous material, the reinforcement layerincluding a first surface configured to face an abdominal wall and asecond surface opposite the first surface, the reinforcement layer beingdelimited by an outer edge, at least one first barrier layer, includinga biocompatible anti-adhesion material, the first barrier layerincluding a first surface and a second surface opposite the firstsurface of the first barrier layer, the first surface of the firstbarrier layer covering substantially at least a central part of an areaof the second surface of the reinforcement layer, the second surface ofthe first barrier layer configured to face the abdominal cavity, thefirst barrier layer being delimited by an outer edge, and at least onesecond barrier layer, the second barrier layer being shaped anddimensioned so as to cover at least a part of the area of the secondsurface of the reinforcement layer that is not covered by the firstbarrier layer, the second barrier layer including one or more flapmembers, each flap member being formed of a piece of sheet ofbiocompatible anti-adhesion material, and having at least an outer edgeattached to the second surface of the reinforcement layer and a freeinner edge, positioning the prosthesis with the first surface of thereinforcement layer facing the abdominal wall, lifting the free inneredge of the one or more flap members to access a protected space betweenthe second barrier layer and at least one of the second surface of thefirst barrier layer or the second surface of the reinforcement layer,and fixating the prosthesis to the abdominal wall with a fixating meanspositioned within the protected space and covered by the at least onesecond barrier layer.
 19. The method of claim 18, wherein fixating theprosthesis further comprises introducing a fixating tool into theprotected space to apply the fixating means into the protected space andthe abdominal wall.
 20. The method of claim 18, wherein the fixatingmeans is selected from the group consisting of clips, tacks, screws,straps, spirals, staples, and sutures.
 21. The method of claim 18,wherein the fixating means is a tack.
 22. The method of claim 18,wherein lifting the free inner edge of the one or more flap membersincludes grasping one or more projecting tabs extending from the freeinner edge towards a central part of the first barrier layer, the one ormore projecting tabs configured to help the surgeon lift the one or moreflap members.
 23. The method of claim 18, wherein the introducing of theprosthesis includes passing the prosthesis in a folded configurationthrough a trocar.
 24. The method of claim 18, further comprisinginsufflating of the abdominal cavity and reduction of a hernial sac ofthe hernia prior to introducing of the prosthesis.
 25. The method ofclaim 18, wherein the second barrier layer includes at least a firstflap member having a form of an annular band, an outer edge of the firstflap member being substantially attached to the second surface of thereinforcement layer along the outer edge of the reinforcement layer. 26.The method of claim 25, wherein the second barrier layer furtherincludes at least a second flap member, the an outer edge of the secondflap member being substantially attached to the second surface of thereinforcement layer along a line located between the outer edge of thereinforcement layer and the outer edge of the first barrier layer. 27.The method of claim 26, wherein the second flap member has the form of asecond annular band, the first and second flap members beingconcentrically positioned one with respect to the other, so that theouter edge of the second flap member is substantially attached to thesecond surface of the reinforcement layer along a line substantiallyparallel to the outer edge of the reinforcement layer, the line beinglocated between the outer edge of the reinforcement layer and the outeredge of the first barrier layer.
 29. The method of claim 26, wherein thesecond barrier layer further includes a third flap member having anouter edge, each of the second and third flap member having the form ofa tape portion, the respective outer edges of the second and third flapmembers being substantially attached to the second surface of thereinforcement layer along line(s) located between the outer edge of thereinforcement layer and the outer edge of the first barrier layer, theline(s) being intended to be positioned in regards of the vicinity ofthe edges of the hernia defect.
 30. The method of claim 25, wherein theouter edge of the first flap member is attached to the second surface ofthe reinforcement layer so as to define an attaching line which isoffset towards a center of the prosthesis from about 0.5 to about 2 cmfrom the outer edge of the reinforcement layer.
 31. The method of claim18, wherein the outer edge of the one or more flap members is attachedto the second surface of the reinforcement layer by attaching meansselected from the group including ultrasonic welding, hot compressionwelding, gluing and combinations thereof.
 32. The method of claim 18,wherein an area resulting from the addition of each area of the one ormore flap members is less than 120% of the part of the area of thesecond surface of the reinforcement layer that is not covered by thefirst barrier layer.
 33. The method of claim 18, wherein the secondbarrier layer is provided with markings intended to indicate to thesurgeon where to locate one or more fixing means for fixing theprosthesis to the abdominal wall.
 34. The method of claim 33, whereinthe markings are colored spots located on a surface of the secondbarrier layer intended to face the abdominal cavity.
 35. The method ofclaim 33, wherein the markings are regularly spaced from one anotheralong a perimeter of the second barrier layer.
 36. The method of claim18, wherein a smallest dimension of a shape of the piece of sheet ofanti-adhesion material forming the one or more flap members ranges fromabout 1 cm to 4 cm.
 37. A prosthesis for treating a hernia defect in anabdominal wall comprising: at least one reinforcement layer, including abiocompatible porous material, the reinforcement layer including a firstsurface configured to face an abdominal wall and a second surfaceopposite the first surface, the reinforcement layer being delimited byan outer edge, at least one first barrier layer, including abiocompatible anti-adhesion material, the first barrier layer includinga first surface and a second surface opposite the first surface of thefirst barrier layer, the first surface of the first barrier layercovering substantially an area of the second surface of thereinforcement layer, the second surface of the first barrier layerconfigured to face the abdominal cavity, the first barrier layer beingdelimited by an outer edge, and a first flap member formed of a piece ofa first sheet of first biocompatible anti-adhesion material, the firstflap member including a first surface and a second surface opposite thefirst surface of the first flap member, the first surface of the firstflap member including an outer edge attached to the second surface ofthe first barrier layer and a free inner edge of the first flap member,free of the first barrier layer, and a second flap member formed of apiece of a second sheet of biocompatible anti-adhesion material, thesecond flap member including a first surface and a second surfaceopposite the first surface of the second flap member, the first surfaceof the second flap member including an outer edge attached to the secondsurface of the first flap member and a free inner edge free of the firstflap member.